A biopsychosocial-spiritual approach means asking about four things at every visit: the body (medical conditions, labs, sleep, substances), the mind (thought patterns and beliefs about treatment), the social world (work, relationships, money) and sources of meaning (faith, community, purpose). Each one changes what is prescribed and how well it works. The physician's own beliefs stay out of the room.
My practice profile says I work within a biopsychosocial-spiritual framework. That phrase can sound like a slogan, so I want to explain what it means in the one place where patients actually encounter it: a medication visit. The short version is that I treat the condition in the context of the person, and I ask about four dimensions of that person every time, because each one changes what I prescribe and how I expect it to work.
Where the model comes from
In 1977 the psychiatrist George Engel published a paper in the journal Science arguing that the biomedical model, which treats illness as a disorder of the body alone, was too narrow for medicine and especially for psychiatry. He proposed a biopsychosocial model: illness is produced and maintained by biological, psychological and social factors acting together, and a physician who attends to only one of them will treat only part of the problem. The model became the standard way of teaching psychiatry, and it is how I was trained at the Medical College of Georgia.
The spiritual dimension was added later, most clearly by Daniel Sulmasy, a physician and ethicist who argued in 2002 that patients are also beings who seek meaning, and that illness raises questions about purpose, suffering and hope that the other three dimensions do not reach. Surveys consistently show that most Americans consider themselves religious or spiritual and that many want their physicians to be aware of it. The Joint Commission, which accredits hospitals, requires a spiritual assessment of patients for this reason. In psychiatry, where the questions of meaning are often the illness itself, leaving this out seemed to me incomplete.
Biological: what I do with the body
This is the part people expect from a psychiatrist. I take a full medical history, because thyroid disease, anemia, vitamin deficiencies, sleep apnea, chronic pain and many medications produce or worsen psychiatric symptoms. I order laboratory tests when the picture calls for them. I ask about sleep in detail, about alcohol and other substances and about family history of mental illness and of response to specific medications, because both run in families.
Then I prescribe, when prescribing is warranted, with attention to the body the medication is going into. A patient with high blood pressure, a cardiac history, liver disease, obesity or diabetes gets a different medication from one without those conditions. A patient on an antipsychotic gets a schedule of metabolic monitoring. The biological dimension does not stop at the brain.
Psychological: what I do with the mind
Medication changes the chemistry that sustains a depression or an anxiety disorder. It does not change the patterns of thinking and behavior that grew up around the illness: the avoidance that keeps panic alive, the self-criticism that deepens depression, the rumination that keeps a person awake. In a medication visit I ask how the patient explains their own symptoms, what they do when the symptoms are worst and what has helped before. I offer brief, practical interventions within the visit, and I refer for structured psychotherapy when the pattern needs more than I can address in twenty minutes. The evidence that medication plus psychotherapy outperforms either alone for most conditions is strong, and I say so.
The psychological dimension also includes how a person feels about taking medication at all. A patient who sees a prescription as a personal failure will not take it reliably. That belief is worth ten minutes of conversation, because the best medication in the world does not work in the bottle.
Social: what I do with the world around the patient
I ask about work, money, housing, relationships, caregiving and isolation. These are not background details. A depression that is being fed by a job that demands seventy hours a week, a marriage in collapse or the loneliness of a recent move will not fully respond to medication while those conditions persist, and a patient who understands that can make decisions about them. Conversely, a patient with strong relationships, a stable routine and work they find meaningful has resources that make every treatment work better.
The social dimension also includes the practical: can the patient afford the medication, get to the pharmacy, take time off for follow-up visits? A plan that ignores these questions fails on logistics, and I would rather know now.
Spiritual: what I ask and what I do not do
This is the dimension that needs the most explanation. I am a person of faith, and that is public knowledge. It does not mean that I bring my beliefs into the room. It means that I take seriously the role that a patient's own beliefs play in their illness and recovery, whatever those beliefs are, including none.
In practice I ask a few open questions. Is faith or spirituality important to you? Does it help you cope, or has it become a source of distress? Are you part of a community that supports you? The answers matter clinically. A person who has lost the faith that anchored them is grieving something that an antidepressant does not restore. A person whose religious community is a source of shame about mental illness or medication may need help reconciling treatment with belief, and sometimes a conversation with a clergy member they trust is part of the plan. A person who finds meaning in service, in nature or in their work has a resource I want to name and protect.
What I do not do is proselytize, prescribe prayer in place of medication or treat a patient's beliefs as symptoms. Religious content can appear in psychosis and in severe depression, and distinguishing between a sincere belief and a symptom is part of my training. I handle it with the same care I bring to any other part of the history, and I follow the patient's lead on how much they want to say.
How this changes a twenty-minute visit
A follow-up medication visit with me includes a rating scale, a review of side effects and a decision about the prescription, like any other. It also includes a few questions from each of the four dimensions: how the body is doing, how the patient is thinking about the illness, what is happening at work and at home, and whether the things that give life meaning are still available to them. It adds a few minutes. In return I usually understand why a medication is or is not working, which is the information I need to make the next decision well.
That is what biopsychosocial-spiritual means in my office. Not a philosophy to be admired, but a checklist that keeps me from treating a prescription as if it were the whole person.
Frequently asked questions
Does Dr. Gobar bring religion into treatment?
No. He asks whether faith or spirituality is important to the patient and whether it helps or causes distress, because the answer affects treatment. He does not share his own beliefs or substitute prayer for medication.
Where does the biopsychosocial model come from?
George Engel proposed it in a 1977 paper in Science, arguing that illness arises from biological, psychological and social factors together. Daniel Sulmasy and others later added the spiritual dimension.
Why ask about work and relationships in a medication visit?
Because a depression fed by an unmanageable job or a collapsing marriage will not fully respond to medication while those conditions persist, and because practical barriers such as cost and time off determine whether a plan can be followed.
More from Dr. Gobar
- How I think about changing an antidepressant that has stopped working
- Psychosis is treatable: what I tell families at the first visit
- Work stress or something more: how I tell the difference
Educational content and not a substitute for evaluation. If you are in crisis, call or text 988.